Thomas Melchior

The impact of heart failure on prognosis of diabetic and non-diabetic patients with myocardial infarction: a 15-year follow-up study

Information about the occurrence of heart failure in the acute phase of myocardial infarction (MI) in diabetic patients and its impact on prognosis are sparse.

Clinical Characteristics, Left and Right Ventricular Ejection Fraction, and Long-term Prognosis in Patients with Non-insulin-dependent Diabetes Surviving an Acute Myocardial Infarction

Patients with diabetes mellitus have a high morbidity and mortality from acute myocardial infarction, the reason for which is not fully understood. The relationship between congestive heart failure symptoms, left ventricular ejection fraction, and long‐term mortality was examined in 578 hospital survivors of acute myocardial infarction, 47 of whom had Type 2 (non‐insulin‐dependent) diabetes mellitus. None of the patients were treated with insulin. The prevalence of congestive heart failure during hospitalization was similar in patients with and without diabetes, although mean diuretic dose was higher in the former patients. Left and right ventricular ejection fraction was measured with radionuclide ventriculography in the second week after acute myocardial infarction. At discharge from the coronary care unit, patients with and without diabetes had similar left ventricular ejection fraction (with diabetes: median 46% vs without diabetes: median 43%; p = 0.89). Median right ventricular ejection fraction (62 %) was within normal limits in both groups and did not differ statistically. Survival data were obtained for all patients. The 5‐year mortality was increased in patients with diabetes compared with non‐diabetic patients independent of left ventricular ejection fraction. Univariate analysis showed that the cumulative 5‐year mortality rate was 53 % in the group with diabetes compared with 43% in the non‐diabetic group (p = 0.007). Using multivariate regression analysis presence of diabetes was found to have a significant association with long‐term mortality after myocardial infarction, that was independent of age, history of hypertension, congestive heart failure symptoms during hospitalization or of either left or right ventricular ejection fractions at discharge. We conclude that the excess mortality in patients with non‐insulin‐dependent diabetes mellitus is not explained by available risk markers after myocardial infarction. Even though left ventricular ejection fraction and serum creatinine did not differ significantly, the apparent higher dose of Frusemide in patients with than without non‐insulin‐dependent diabetes mellitus might indicate that heart failure, if present, is more severe in patients with than in those without diabetes. The importance of diastolic dysfunction in this context needs to be determined.

Aortic dissection in the thrombolytic era: early recognition and optimal management is a prerequisite for increased survival

Based on two case reports, problems of diagnosis and treatment of aortic dissection are discussed. Thrombolytic treatment given to patients with aortic dissection presenting symptoms mimicking acute MI seems to have a fatal outcome. Indications, as well as contra-indications, for thrombolytic therapy are therefore of great importance, when this treatment is given to patients suspected of having acute myocardial infarction, especially where diagnosis is uncertain or as prehospital treatment. In patients with chest pain symptoms without typical history and electrocardiographic changes the diagnosis should be reconsidered within a few hours and, if possible, together with echocardiographic findings. In doing so patients with coronary heart disease will get all the benefits of thrombolytic treatment. Furthermore the importance of quick accurate diagnosis, especially in type A aortic dissection is pointed out, as emergency surgical intervention can be lifesaving. A more aggressive medical and surgical approach has contributed to the improved survival among patients with aortic dissections.

Prevalence and characteristics of impaired glucose metabolism in patients referred to comprehensive cardiac rehabilitation: the DANSUK study.

Background Lifestyle and pharmacological interventions can delay the progression of impaired glucose tolerance (IGT) to type 2 diabetes (T2DM), and there is growing evidence that earlier detection of T2DM and intensified risk factor management may result in improved cardiovascular morbidity and mortality. We studied the prevalence of impaired glucose metabolism (T2DM, IGT and impaired fasting glucose; IFG) in patients referred to cardiac rehabilitation, and further studied whether we could identify groups in which an oral glucose tolerance test (OGTT) need not be performed. Methods As part of a cardiac rehabilitation trial, 201 patients participated. Patients without a diagnosis of T2DM (N = 159) underwent an OGTT 3 months after inclusion. Results Forty-two patients (21%) had known T2DM at enrolment. Based on the OGTT, 26 patients (13%) had unrecognized T2DM, 36 (18%) had IGT and 19 (9%) were diagnosed with isolated IFG according to the World Health Organization definition. Using fasting plasma glucose alone, 19% of the patients with unrecognized T2DM and two-thirds of patients with IGT would be misclassified. Using IFG as a means to detect IGT showed a sensitivity of only 33% and a positive predictive value of 39%. Conclusion More than 60% of the patients (123/201) referred to cardiac rehabilitation had impaired glucose metabolism and 18% of the screened patients (29/159) would be misclassified if an OGTT was omitted. IFG and IGT did not identify the same patients or the same cardiovascular risk profile. An OGTT test should therefore be considered a constituent part of routine care management in cardiac rehabilitation settings.

Do Diabetes Mellitus and Systemic Hypertension Predispose to Left Ventricular Free Wall Rupture in Acute Myocardial Infarction

Diabetes and systemic hypertension had no influence on left ventricular free wall rupture complicating acute myocardial infarction. Age <65 years and a history of coronary artery disease offers some protection from protection.

Effects of amlodipine and isosorbide dinitrate on exercise-induced and ambulatory ischemia in patients with chronic stable angina pectoris

This study was designed to compare once-daily administration of 5–10 mg amlodipine with two daily doses of 40 mg sustained-release isosorbide dinitrate in 59 patients with stable angina using a randomized, double-blind, crossover study design. Anginal episodes, nitroglycerin consumption, and possible adverse events were recorded in a diary. A maximal symptom-limited bicycle exercise test and 48-hour ambulatory ECG monitoring were performed at baseline and at the end of each 5-week period of therapy. Exercise time, time to angina, time to ST depression, and maximal ST depression were measured during exercise. During ambulatory monitoring, the number of ischemic episodes and the duration per hour of ST depression were assessed. Amlodipine significantly reduced anginal episodes (P < 0.001) when compared with isosorbide dinitrate. Furthermore, amlodipine prolonged time to ST depression (P < 0.001) and time to angina (P < 0.05) when compared with isosorbide dinitrate. The number and duration of ischemic episodes during ambulatory monitoring were significantly reduced with amlodipine when compared with baseline values (P < 0.05), whereas no differences were found between isosorbide dinitrate and baseline. Adverse events were reported more frequently with isosorbide dinitrate than with amlodipine (P < 0.02). Amlodipine appears to be more effective and tolerable than sustained-release isosorbide dinitrate as monotherapy for chronic stable angina.